Privia Medical Group launched in 2013 to help independent physicians remain autonomous and adapt to value-based care with the support of a larger network and the right technology. In that way, the missions of Privia Health and athenahealth are closely aligned, so it’s not surprising that Privia Medical Group, the organization’s high-performance physician group, uses both athenaOne (which includes electronic health records and revenue-cycle management services) and athenahealth Population Health.

Clinicians in Privia Medical Group span New York, the Mid-Atlantic, Georgia, and parts of Texas. Many are part of Privia Quality Network, the organization’s ACO, and all rely upon Privia’s support as they transition to population health management and value-based care payment models.

The demands of value-based care

The biggest challenge Privia’s clinicians face today is knowing how to satisfy different health plans’ requirements. “Based on whatever insurance patients have, [clinicians] need to focus on this quality gap versus that quality gap,” says Sam Starbuck, associate director, new product development at Privia Health. “A doctor didn’t go to school to learn how to code or to learn how to check a box in the EHR,” says Starbuck.

Delivering results on the quality measures included in their risk-based agreements is an important strategic priority for Privia’s care sites, but the challenges to doing so extend beyond documenting in the EHR. First, clinicians need to make sure they’re getting patients into the office at the right time, especially when it comes to receiving preventive care.

Automated outreach to engage patients

The Annual Wellness Visit for Medicare patients is an important milestone for Privia’s care sites. In addition to providing needed care, clinicians can close 10 to 15 quality gaps in one visit, says Starbuck. athenahealth analysis confirms that eligible Medicare patients who get an Annual Wellness Visit are more likely to satisfy 10 other CMS ACO quality measures as well.¹ With so many potential benefits, when Privia partnered with athenahealth to conduct their first patient outreach campaign using the Population Health service, they decided to start with the Medicare Annual Wellness Visit (MAWV).

For this pilot initiative, athenahealth’s in-house Performance Management team leveraged the clinical and claims data aggregated in the Population Health application to identify which of Privia’s eligible patients had not had a Medicare Annual Wellness Visit. Using best practices gathered from athenahealth’s network of clients and in-house consumer marketing expertise, the team then worked with Privia to design and execute a three-week drip campaign with prescheduled, automated messages.

To support the campaign, athenahealth designed personalized emails with Privia branding and both the patient’s and clinician’s name to prompt patients to schedule a MAWV. Finally, athenahealth determined the optimal timing to send messages automatically via Outreach Manager, the patient outreach platform within Population Health. As a drip campaign, if patients did not respond to the initial message, the service automatically sent a follow-up email message and phone call, which followed a customized script created by athenahealth.

In total, the pilot campaigns reached 960 unique patients in four of Privia’s care centers. Within 45 days of being contacted, more than 30 percent of those patients took action to schedule an appointment. Because Privia uses both athenaOne and the athenahealth Population Health service, athenahealth was able to analyze data from EHR, patient portal, and Population Health sources to track the impact of the campaigns on Privia’s clinicians across the athenahealth network.

The campaigns filled care centers’ schedules and got patients back into the office. Privia’s care centers “are appreciative of the additional revenue and of the support that we’re providing,” says Starbuck.

Scale outreach, not staff

Initially, Privia was conducting this kind of patient outreach manually in-house. Each member of a two-person team called 80 to 100 patients per day. Reaching out to all eligible patients would have required a staff of 20 to 30, Starbuck estimates. athenahealth’s ability to scale this function to serve its entire client base brings greater efficiencies, without an increase in overhead for Privia. Conducting manual outreach to 960 patients would have taken Privia staff about 128 hours.²

“It was just an opportunity to allow us to scale our resources in a much more tactical way, while also leveraging some of the best practices and knowledge that [athenahealth has] gained in doing this,” says Starbuck. “We’re now able to refocus the team on other high-value activities without having to make the investment of scaling a team to meet our at-risk populations’ scheduling needs.”

Those higher-value tasks include transitional care management phone calls for patients coming out of the Emergency Department, scheduling specialist appointments for at-risk patients, and supporting care managers in identifying gaps in care.

Improved quality performance

Reducing the total cost of care through improved quality is an important strategic objective for Privia. Through the Outreach Manager campaigns, they had the opportunity to close between 3,000 and 4,500 care gaps.³ Within a few months of the campaign, MAWVs had been billed for nearly one-third of eligible patients. Nationally, only about 16 percent of Medicare beneficiaries have an Annual Wellness Visit.⁴ These visits will likely create an even bigger impact on Privia’s overall quality performance since Medicare patients are more likely to satisfy other quality measures when they get an Annual Wellness Visit.⁵

Given the ease and effectiveness of implementing the Outreach Manager campaigns, Starbuck hopes to expand their use in promoting the Medicare Annual Wellness Visit, as that encounter “addresses quality management, it’s positive for the patient, and it also brings in ROI to the care center,” says Starbuck. Bringing in more Medicare patients for Annual Wellness Visits “provides multiple layers of benefits to the patient, our providers, and to Privia Medical Group as a whole.”